Integrated Dual Disorders Treatment

The term “dual diagnosis” refers to the co-occurrence of substance abuse and severe mental illness. Since the problem of dual diagnosis became clinically apparent in the early 1980s, researchers have established three basic and consistent findings:

  • co-occurrence is common – about 50 percent of individuals with severe mental disorders are affected by substance abuse
  • dual diagnosis is associated with a variety of negative outcomes, including higher rates of relapse, hospitalization, violence, incarceration, homelessness, and serious infections such as HIV and hepatitis
  • the parallel but separate behavioral health and substance abuse treatment systems so common in the United States deliver fragmented and ineffective care.

Most clients are unable to navigate the separate systems or make sense of different messages about treatment and recovery. Often they are excluded or removed from services in one system because of the co-morbid disorder and told to return when the other problem is under control. For those reasons, clinicians, administrators, researchers, family organizations, and clients themselves have been calling for the integration of behavioral health and substance abuse services for at least 15 years.

Dual diagnosis treatments combine or integrate behavioral health and substance abuse interventions at the level of the clinical interaction. This means that the same clinicians or teams of clinicians, working in one setting, provide appropriate behavioral health and substance abuse interventions in a coordinated fashion. For the individual with a dual diagnosis, the services appear seamless, with a consistent approach, philosophy, and set of recommendations. The need to negotiate with separate clinical teams, programs, or systems disappears.

The goal of dual diagnosis interventions is recovery from two serious illnesses. In this context, “recovery” means that the individual with a dual diagnosis learns to manage both illnesses so that he or she can pursue meaningful life goals.

The Ohio SAMI Coordinating Center of Excellence (CCOE) has created a brief six-page overview of the IDDT model, with emphasis on the Treatment Characteristics. It was distributed at the CCOE’s Annual Conference in September. The PDF version is now available online (see hyperlink below). If you would like a printed copy, contact the CCOE.

Integrated dual disorders treatment is for all consumers with both substance abuse or dependence disorders and mental illnesses, such schizophrenia, bipolar disorder, or depression.

Several components of integrated programs can be considered evidence based practices because they are almost always present in programs that have demonstrated good outcomes in controlled studies and because their absence is associated with predictable failures.

Integration of Substance Abuse and Mental Health Treatment
Integration means same team of providers offer behavioral health and substance abuse treatment in the same location at the same time.

Staged Interventions
Effective programs incorporate, implicitly or explicitly, the concept of stages of treatment. In the simplest conceptualization, stages of treatment include forming a trusting relationship (engagement), helping the engaged client develop the motivation to become involved in recovery-oriented interventions (persuasion), helping the motivated client acquire skills and supports for controlling illnesses and pursuing goals (active treatment), and helping the client in stable remission develop and use strategies for maintaining recovery (relapse prevention).

Assertive Outreach
Effective programs engage clients and members of their support systems by providing assertive outreach, usually through some combination of intensive case management and meetings in the client’s residence.

Motivational Interventions
Effective programs incorporate motivational interventions that are designed to help clients become ready for more definitive interventions aimed at illness self-management.

Effective programs provide some form of counseling that promotes cognitive and behavioral skills at this stage. The counseling takes different forms and formats, such as group, individual, or family therapy or a combination.
Social support interventions
In addition to helping clients build skills for managing their illness and pursuing goals, effective programs focus on strengthening the immediate social environment to help them modify their behavior.

Long-term Perspective
Effective programs recognize that recovery tends to occur over months or years in the community. They take a long-term, community-based perspective that includes rehabilitation activities to prevent relapses and to enhance gains.

In effective programs attention to substance abuse as well as mental illness is integrated into all aspects of the existing mental health program and service system rather than isolated as a discrete substance abuse treatment intervention. Inpatient hospitalization, assessment, crisis intervention, medication management, money management, laboratory screening, housing, and vocational rehabilitation incorporate special features that are tailored specifically for dual diagnosis patients.

Cultural Sensitivity and Competence
A fundamental finding of research studies is that cultural sensitivity and competence are critical to engaging clients in dual diagnosis services.

Research on integrated dual disorder treatment indicates that the following outcomes result from programs that meet fidelity standards:

  • Stable remission of substance abuse
  • Reduction in hospitalization
  • Housing stability
  • Decrease in psychiatric symptoms
  • Decrease in arrests
  • Increase in functional status
  • Increase in quality of life